Obstetric
lacerations are a common complication of vaginal delivery.
Lacerations can lead to
chronic pain and urinary and
fecal incontinence. Perineal
lacerations are defined by the depth of musculature involved, with fourth-degree
lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree
lacerations having no perineal muscle involvement. Late third-trimester perineal
massage can reduce
lacerations in primiparous women; perineal support and
massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Conservative care of minor
hemostatic first- and second-degree
lacerations without anatomic distortion reduces
pain,
analgesia use, and
dyspareunia. Minor
hemostatic lesions with anatomic disruption can be repaired with surgical glue. Second-degree
lacerations are best repaired with a single continuous
suture.
Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling
pain, preventing
constipation, and monitoring for
urinary retention.
Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed.
Opiates should be avoided to decrease risk of
constipation; need for
opiates suggests
infection or problem with the repair. Osmotic
laxative use leads to earlier bowel movements and less
pain during the first bowel movement. Simulation models are recommended for surgical technique instruction and maintenance, especially for third- and fourth-degree repairs.